jeudi 31 décembre 2020

A FULL MOON AND A WELCOME WITH RELIEF OF A NEW YEAR 31.12.2021

 on 29th december 2020, the last full moon of the decade appears and as the Indians call it   the winter moon or the moon that brings the winter..



I received the following Video from Brasil .. thank you 

the bright moon continued to grace the skies for the shorter nights before the new year..

View from the backyard of my sisters home in Miami.

An indigenous photographer has been enjoying the brightly lit nights over their homes in their lands far away from the prying eyes .. he sent me this photo tonight

I told him, as we enter 2021. this photo brings us hope, light and desire for better things for every one on earth and consideration for others and perhaps an increased compassion and a new path to happiness..

CELESTIAL MAGIC OF DECEMBER 21

 



I had been waiting for this day, 21 december 2020. Normally it is just the Winter Solstice. Even in this tropical clime, during this time of the year, the sun sets early. With so many of our accoutrements tellings us when the sun sets, to day it was supposed to be 17.26, I rushed from the National Park where I was to the place I was staying in MIami.
On the way could not help notice the beauty of the setting sun.






By the roadside I saw people setting up their telescopes and I stopped for a moment as the sun dipped below the horizon.

it was the celestial dance of Jupiter and Saturn, the conjunction which had been labelled the Bethlehem star ..(etymology fans may like:  The term bedlam comes from the name of a hospital in London, “Saint Mary of Bethlehem,” which was devoted to treating the mentally ill in the 1400s.)





It was a special night.I was staying at the farm of friends of mine away from Miami and the sky was clear and one could see hundreds and thousands of stars.
Jupiter and its bands and Saturn and its rings were visible on projections sent on line from various universities. Even though they were million miles apart (456 million miles to be exact)..
Mark your calendars. 15 march 2060 for the next meeting of Jupiter and Saturn (easily visible, than the 2040 reunion)
to a little bit left of the MOON , one could even get a glimpse of Mars on this night.

a special night 
astrologers would talk of an auspicious beginning of a new era in human relationships ..


NURSES VISITING PATIENTS AT HOME AND RELAYING INFORMATION TO THE CLINIC: A VITAL PART OF HEALTH CARE AND ANTHROPOLOGICALLY APPROPRIATE

 This is a presentation I gave to a group of Visiting Nurses/Home Health Nurses.

I will write commentaries on each of the slides and hope that many nurses get to see this presentation.

When there is SUFFERING due to a Chronic Disease, the curing and healing aspects can be sought amongst all the people who are in touch with the patient.

Visiting Nurses, Home Health Nurses and Community Health Representatives are golden resources in the path of healing for the patients.

Pre-Covid and OJALA, post-covid my world was International Humanitarian Medicine, to which I will return.


I have worked with some great Diabetes Educators during my multiple visits to the USA. I am very grateful for their help and friendship and I think of my UmonHon Indian relatives Michele S and Ashleen BB, both of whom are Diabetes Educators.

Diabetes Care is best provided outside the Clinical Setting and various members of the team taking EQUAL responsibility for the healing outcome
Over the years, I have worked with Massage Therapists, Physical Therapists, Psychological counsellors, Pharmacists, Exercise Educators and each of us do the best we can.
Nurses are an INTEGRAL part of this team

At the Wellness Centre, you can bring your patients for a variety of services. 

One of the first observations I made when I began working with American Indians was that some were getting better and some patients were not getting better despite the therapy being more or less equivalent. I divided the patients receiving Medical care into three categories  A. those who had CHR Community Health Representative or Home visits by Nurses   B. Nurse Practitioners two of them who were Indians. C. Medical Doctors who were Family Physicians
Which group had the best outcome in terms of measured A1C? The group who had home health nurse visits (attached to the Clinic belonging to the Public Health Nurse System) and CHR!
Were the others not good at taking care of Diabetes? No that is not the conclusion. Patients felt much at home, could ask anything they desired and over the course of time they build up relationships.
The best diabetes care outcome was with Nurses/CHR with whom the patients had built a good RELATIONSHIP. More I read the history of Native people, the more I realize the importance of RELATIONSHIPS. Lakota say Mitakuye Oyasin, we are all related!
Native people are not impressed with where you went to medical school, whether your Doctor degree is in Audiology or what Board Certification you have. They are cognizant about one thing: Do you care for them. They are very good at assessing this because they can interpret symbols very well, in the context of their own lives.
At another Indigenous clinic I advised a visiting doctor to dress down from his Armani suits to something simple but clean as that particular group of Indians saw these symbols as symbols of oppression by white people.
We have to stop thinking of our bodies as MACHINES and our bodies do not follow mechanical equations. In each of our bodies someone lives who has a mind of their own.
Majority of the calories in the american diet comes from ultra processed food and a take out from PF Chang's is no exception. 
after a meal from PF Chang's the Blood sugar went up a good 60 mg/dl and what was important that it was not coming down as the time went by 
Our patient complicated the matter by eating an Indian Taco, there is nothing INDIAN about Indian Taco . It is like calling Taco John's a mexican taste..
Even the next day, his blood sugar remained high and only by cutting down on his meals and eating simple meals was he able to bring down his blood sugar.
Ultra processed food contain an enormous amount of chemicals with flavours of food and very seldom any FOOD of nutritional value. These chemicals interfere with the body's metabolism and may be responsible for the array of suffering and diseases and illnesses among the modern men and women





TWO PIECES OF ADVICE FROM DIFFERENT. PARTS OF THE WORLD. 31.12.2020

  Jeff Bezos, Mr. Amazon, was a precocious kid who once told his grandmother, who was fond of smoking, how to calculate the number of days of life lost by smoking. She was not amused and she told him

IT IS HARDER TO BE KIND THAN CLEVER.

Think about it, we pay attention to clever people and very often neglect people who are kind. The society rewards CLEVER people but lays aside the KIND ones.

Dalai Lama was quoted as saying

If you wish to make another person happy, BE COMPASSIONATE

If you wish to make yourself happy, BE COMPASSIONATE .


the second piece of advice came from SADHGURU who was giving his end of the year lecture from India


UNHAPPY people are unwilling to change whereas HAPPY people are willing to change their behaviour, but it is the UNHAPPY people who need to change.


Alain de Boton the British philosopher had said: If you pride yourself being SUCCESSFUL, remember you are a failure at many other things. You call yourself successful by the rules set by the society you live in .

IF YOU WANT RELIABLE AND TRUTHFUL NEWS, BE PREPARED TO PAY FOR IT

It was one of my professors of Medicine in Miami, Dr Howard Lessner, Olav ha shalom, who said to me: the drug companies would send you lots of free materials and glossy magazines but get your medical information from subscriptions, that you pay for, such as New England Journal of Medicine, BMJ, Lancet, JAMA etc.

Yuval Noah Harari recently reminded us of this: CNN or Yahoo News or Fox News should not be your source of information. Pay for your news. 

As the year was ending I renewed that promise once again.

Ever since I was a student in Australia I had read The Economist an erudite magazine ( I recommend it to the learners of the English language so that they can improve their vocabulary, have a dictionary handy) covering what is happening in this world. If you live in USA long enough, you can see how quickly you can become ignorant of what is happening in the world. 

While i am in Miami, I do not watch TV at all and do not lisen to any news channel, making an exception for the Public Radio when I am travelling through desolate parts of this country to visit the Indigenous people.

I renewed my subscription to The Economist . 

The local newspaper in Miami is called Miami Herald and it can be classified as one of the worst newspapers in the world if not in the universe ! I avoid it like a plague and when I rea their reports on Cuba I know that they have no idea of the place they are writing about! 

But USA has given us one of the best newspapers in the world: The New York Times

Each day they send me a summary of the headlinese but if you want to read in depth or read the analyses , one has to subscribe to it 

That is what i did to day.

Subscribed to the New York Times.

So i have now enough to keep me occupied and keep me in this planet and not just in this isolated paroquial place called Miami!

lundi 28 décembre 2020

A SPECIAL DEATH: REMEMBERING THE MAHARAJAH OF SERI KEMBANGAN AND HIS TWO COURTIERS

A special death 


There are special deaths, but only Special people deserve that.


Death comes out of season, said the Great Orator of the Omaha, The Little Elk. We can't prepare for it.


My friend in Southeast Asia had been influenced by her mother, who had been a gentle soul and kind one to boot and had adopted an orphan at birth.

When the child was growing up, it soon became evident that he was autistic. The kind woman showed no difference to him from the two natural female children she has and he grew up in that glow.

An untimely illness took her away and thus began the rocky road, thank god it was brief for the Maharajah of Seri Kembangan, as I had nicknamed him when I met him about 10 years ago. 

Like all men-children, they are closer to the creation of God and maintain an innocence beyond our conception and that which we had hastily forgotten many years ago. 

My best friend took him in after custody battles and provided him with the best of love and affection which he reciprocated and they included him in many of her social activities with her husband. 

To care for him at home while she pursued her postgraduate studies would have been an immense sacrifice, as his beloved nanny also passed away and after much discussion, it was decided for him to live in a shared facility run by some wonderful people.

My best friend and her husband took him out on journeys, spent time with him, he delighted in his cake afternoons. 

The season of Covid put an end to a lot of such activities. But their contacts continued to the delight of everyone concerned.

On a recent afternoon he complained of shortness or breath and was taken to the Casualty of the nearest hospital and soon was pronounced dead. Covid was ruled out and sudden death was the diagnosis with aetiology to be determined after an autopsy.



He was given the traditional rites of Chinese burial and rites were carried out. His last resting place would be the sea near the biggest city, where a solemn farewell reminded of those present the onslaught of the absence of the sweetness he had provided in his brief life.

Death comes unexpectedly, said Little Elk. But Maharajah had been calculating it well. His work had been done, he had provided what he could to the best of his ability and now he had to move on. 


Two passages came to my mind. I had met the Maharajah on various occasions, the last time being a dinner at a Chinese restaurant with friends present.

Whoever read Herman Hesse’s The Journey to the East which at one time was a reading of rite of passage can forget the sentence: when we become aware of the loss of someone, our missing of them increases. Thus what they meant to us is enlarged.

Fernando Pessoa had written about someone who casually crossed his path on a regular basis, and only when he was absent he became aware of the immense presence that person was in his life.

I have experienced both to greater and smaller degree. I will never forget the tabac owner of the Place Amborix in Quartier European in Brussels where his grumpy voice grudgingly accepted the 25 centimes from the Little Poet for a candy. Only when the Tabac closed and grumpy old man with tobacco tingle fingers disappeared did I realise the importance of him in my life. 

A retired artist, is he Cuban?, who regularly walks In front of my sister's house Miami, one day he is bald and the other day he is well clad, I have never said hello to him nor do I know his name, but if one day passes that I do not see him, I begin to wonder about him.

The Maharajah of SKB, was amidst us in disguise, clever, making us learn about love and affection and temporal nature of life. He just slipped away, as if he was going for an afternoon walk.



I was walking along the seawall of Havana. I had specially worn a tee shirt from Siem Reap in Cambodia with a painting of a friend of mine, Stef. My best friend was with me when I met the artist years ago and I had brought them two shirts with Stef’s paintings. The Maharajah sported one of them and he travelled to the other world wearing that tee shirt. 


I have one such tee shirt, I put it on, on a nice day , just a few days after the departure of the Maharajah, as the red glow of the sun on the horizon sent caressing messages, I said my goodbye to the Maharajah and said the traditional prayer for the departed in the language of my ancestors.


Travel well Maharajah, your mother and Nanny are waiting with your favourite cake and drink …and as a doctor who studies metabolism, please go slow on the cakes !

And from your exalted position, close to the Spirits, take pity on   your sister and brother in law and me too, and intercede on our behalf with the spirits, so that the three of us can commemorate your presence  with us , continuing with our  work of helping others with the same vigour you demanded of us.

Till all the people whose hearts you had touched are no more, you are alive in their hearts. 

You achieved much in your short life, Maharajah of Seri Kembangan


I was profoundly impressed with selfless love shown to the Maharajah by his sister MunChing and her husband Fernando. Watching the relationship from near and far had a cleansing effect on me. 
I thought to myself: Here are three HUMAN BEINGS at their best..

THANK YOU CHEE FONG, MUN CHING AND FERNANDO


samedi 26 décembre 2020

ANOTHER KUDOS FOR MO PO TSYO THE PEER TO PEER EDUCATOR PROGRAMME IN CAMBODIA RUN BY MY FRIEND MAURITS

I am very proud of my friend Maurits van Pelt and the NGO he heads in Cambodia, MoPoTsyo in which Peer Educators take care of poor people, usually from the slum areas and rural areas, who suffer from Diabetes and Hypertension. Ever since I have known it, I have admired the success of the programme and have maintained my connection with my friend and his programme.

this morning, i had a chance to read the following article.

An innovative model for management of cardiovascular disease risk factors in the low resource setting of Cambodia 

Nazaneen Nikpour Hernandez, Samiha Ismail, Hen Heang, Maurits van Pelt, Miles D Witham, Justine I Davies

 Health Policy and Planning, czaa176, https://doi.org/10.1093/heapol/czaa176

Published:
 
25 December 2020

Authors summary is as follows: and all I can say is: Good on you, mate, Keep up the good work !
  • The author’s institute in Cambodia utilizes Peer Educators (PEs) to screen and manage diabetes and hypertension in the community and a revolving drug fund (RDF) is used to finance the programme.

  • Use of peer educators promotes sustained rates of both hypertension and diabetes control. Attrition rate is variable but substantial.

  • The programme shows a significant and sustained rate of diabetes and hypertension control for those who remain in the program. There is a utility for rolling this model out across Cambodia and in other low- and middle-income country settings; however, further work is needed to improve patient retention.

mercredi 23 décembre 2020

SAUDADE DE RANGUN (RANGOON, YANGON) BIRMANIA BIRMANIE MYANMAR

 I have a lifelong connection with Burma even though my first visit there was in 2003 with my brother Eliyahu. I had heard stories from my biological father about his connection to this land.

My last visit, second of the two visits of 2019, once again reminded me how much humble I feel being with the Burmese, the nicest people of Asia and how grounded I become when I walk along the streets of Yangon. I am one of them, not separate in any fashion, even though my style of living would be alien to them.

All in all, I have visited Myanmar about 20 times and have had the opportunity to visit various nooks and crannies of this very interesting Golden Land and in the course of all these, even earned a name. AUNG KHANT, my burmese name that I am proud of.

I found an appropriate book about walking the various streets of Yangon and was gratified to know that many of the people pictured in the book, I have had the opportunity to meet them on previous occasions or have passed them in the streets depicted in the book.

this corner 27th and Anwharata Road in Indian Town is a corner of fond memories for me. I remember the morning in 2003 when I met the family who has the roadside stall and sewing machine there. I never missed a chance to speak to them when i was in Yangon, even though language was a problem. The lady of the house, A bamar Muslim, would always fetch a cup of Burmese tea, Le Paye, when she see me coming and offer a seat. She had married a grandson of an immigrant from Tamil Nadu who had arrived in the 19th Century.


The children are growing up. They have Burmese and Muslim names, explained Mr Tun Tun whose ancestral name was Tamil: Doraisamy.


I am a homeless doctor but I know that I have little places in the hearts of the Burmese family who has a singer machine and sows and repairs at the corner of 27th street and Anwharata road in Yangon in Myanmar (Rangoon in Burma)


vendredi 18 décembre 2020

USA WHILE LOOSING RESPECT ABROAD FOR ITS POLITICS IS STILL THE CENTRE OF INNOVATION WITH ISRAEL BEING A CLOSE SECOND

 AMERICA OR USA  is a land of immigrants and more so as each year goes by. When you are in a city like Miami you realize that your chance of meeting an American who is not an immigrant or child of an immigrant is virtually ZERO. I am very proud of the fact that I can mingle with Cubans, Venezuelans, Nicaraguans (these three nationalities with diametrically opposite views on life to mine), Jamaicans, Haitians, Colombians, Brasilians and Chileans and not to mention Europeans. The asian and african immigrant population is proportionately less, even then I was not surprised to meet a Nurse of Ugandan Origin when I gave a talk to a group of Nurses, almost all of whom were immigrants to the USA. 

If you look at any field or excellence in the USA, it would be stacked with immigrants or children of Immigrants. All the huge companies that are deployed in our lives have immigrant CEOs or Founders: Amazon, Google, Facebook, eBay, Apple, Yahoo to name just a few..

Covid 19 unfortunately descended upon us and it is interesting to see the people who are involved in its inception and production: Immigrants!

IndividualAffiliationWhere Immigrated From
Charles PfizerFounder of PfizerGermany
Albert BourlaCEO of PfizerGreece
Katalin KarikóSr. V.P. BioNTechHungary
Dr. Ugur SahinFounder of BioNTechTurkey (to Germany)
Dr. Özlem TüreciFounder of BioNTechDaughter of Turkish Immigrants to Germany
Noubar AfeyanChairman and Cofounder of ModernaLebanon and Canada
Derrick RossiCofounder of ModernaCanada
Stéphane BancelCEO of ModernaFrance
Tal ZaksModerna’s Chief Medical OfficerIsrael
Marcello Damiani







Moderna's Chief Digital and Operational Excellence Officer

France




The head of Operation Warp Speed that coordinated the vaccine research is Moroccan migrant to USA from Belgium.

The worldview of an immigrant to another country is different and more often than not, innovative. 

So let us welcome the Immigrants from anywhere in the world to this land where the Original owners of this land, called America but known as Turtle Island to the Natives, welcomed the ancestors of all the people in business and politics, same with Canada, Australia, Mexico, Aotearoa, all of Latin America which is populated by the children of immigrants along with remnants of the original people.

mercredi 16 décembre 2020

A DAY OF RECOGNITION FOR DR PAUL FARMER AS WELL AS MEDICAL ANTHROPOLOGY

Very few Practising Physicians are also Medical Anthropologists, this applies to the entire world. In the USA, there are excellent Medical Anthropologists but the majority of them are not physicians with the exception of Arthur Kleinman and Paul Farmer, both at Harvard. Didier Fassin is French, Jim Yong Kim served as the head of the World Bank, Jean Benoist i French, Egyptian born Tobie Nathan is a French Ethno Psychiatrist, Maurice Eisenberg is in Melbourne, Michael Taussig is an australian located in the USA like his fellow Australian is a Psychiatrist in addition to being an anthropologist. Psychiatry lends itself to study of Anthropology, both concerned with the thinking process of an individual in the context of the society they live in. 

My late teacher, Dr Cecil Helman was both a Physician and an Anthropologist, was a South African based in London. I asked him once, why are there so many jews in the field of Anthropology, and I remember his answer very succinctly: We are the eternal other.

Paul Farmer is neither a Jew nor a Psychiatrist but has had an impressive career in Global Health for the past 30 odd years and has contributed to the knowledge of Medical Anthropology.

During my lectures at the University of Havana, one question often asked by the postgraduate students is: How is Anthropology different from Sociology. It gave me delight to explain that Anthropology creates knowledge whereas Sociology arranges the already known knowledge. Perhaps that is why Anthropology is not popular in totalitarian societies or in those with no thirst for knowledge. The Universities in Asia loathe to introduce courses in Anthropology as the emphasis is on knowledge as a commodity in many cases.

When I was reading Anthropology in London, we had more than occasion to discuss the work of Paul Farmer. He also wrote the best definition of what is Medical Anthropology, as many epidemiologists saunter around as Anthropologists.

I will summarize his words:Medical Anthropology teaches you to divert your gaze from the sterility of the Epidemiologists and Clinicians (pardon the pun) and go beyond facts and figures and transcend to the level of the suffering and focus on the society in which the patient lives.


He is one of the founders of Partners in Health

(one of the others was the medical anthropologist head of World Bank, Dr Kim)


From Paul  Farmer you learn about Structural Violence of the society and about the accusation of blame in the lack of access to medical care which is not a privilege but a right of every one.

Imagine the pleasure, a genuine grin on my face when I was driving to the National Park where the Native people live in this part of the world, this news came over the BBC World Service.
Paul Farmer has been awarded the humanitarian prize 

From NPR 
Dec 16, 2020

When Dr. Paul Farmer learned that he would receive a million-dollar award for his work, he was a bit ... baffled. He is a Harvard Medical School professor, medical anthropologist and co-founder of Partners In Health, an organization whose mission is to bring modern medical care to those in need around the world. But the words "medicine" or "health" do not appear in the award, announced Dec. 16. It is the Berggruen Prize for Philosophy and Culture. "I was a little shocked to get a prize with the word 'philosophy,'" he says.

And yet it's apt, says Nicolas Berggruen, real estate investor and founder of the private equity firm Berggruen Holdings. He founded the Berggruen Institute that awarded the prize to Farmer. "We have a simple idea. It is to reward somebody who is developing new thinking to help society evolve," he says.

Just a small piece of the interview:

In a 2011 address to Harvard students, you talked about a key element of your philosophy of care that you call "accompaniment." You said, "There's an element of mystery and openness in accompaniment: I'll keep you company and share your fate for a while. And not just a little while." The promise to stick with patients through thick and thin seems basic but highly neglected in most medical settings. What does "accompaniment" mean to you in a health-care setting?

I'm an infectious disease specialist. I work in hospitals, in ICUs. But that's just a tiny fraction of what's needed. When people are unable to make choices — if they're in prison, or refugee camps or are impoverished — they're less able to adhere to a treatment. They need help outside the hospital or clinic. In Haiti, community health workers are called accompagnateurs, which means people who accompany. The community health workers do what your mother does for you when you're sick and stay at home. She stays with you, she accompanies you. Accompaniment means: I'll go with you and support you on your journey wherever it leads. I'll keep you company.


I am extremely happy for Dr Paul Farmer and very humbly proud that I am also a Physician-Anthropologist, who to this day does not  have an office or secretary!

A close friend of mine from Brasil send this to me :


OBRIGADO.


dimanche 13 décembre 2020

THE PUZZLE OF VITAMIN D

THE PUZZLE OF VITAMIN D 




It was very exciting to study about Vitamin D metabolism while we were medical students. Called Sunshine Vitamin it was manufactured in the skin from the Sunshine it was exposed to. Then there were two conversion once in the liver and then the active form in the kidney.


When the assays for Vitamin D became widely available two patterns emerged.


 multiple large epidemiological studies have shown that persons with low serum vitamin D levels are at increased risk of multiple adverse health outcomes including osteoporosis, obesity, inflammatory bowel disease, incident diabetes, cardiovascular disease, cancer, and autoimmune disease.


That made me think, if for example for some reason the measurements were wrong, all the people who are sick with anything will have low vitamin  D levels and one would see association with low vitamin  D levels and various diseases.

Of course separately they also found out that vitamin D does affect the microbiomes and the probiotic industry was very happy about that.


Secondly, this is a sunshine vitamin so people who live in countries should not have problems with this vitamin. But their rates of deficiency was no different from colder countries or poorer countries.


Obviously we are measuring something wrong or there is a common factor in the conversion from the skin to the Liver to Kidney.


In the meantime, debates were raging how much vitamin D supplementation should be given and In what form. 


A recent large randomized controlled trial of vitamin D supplementation of over 25,000 adults demonstrated no benefit in preventing cardiovascular events or cancer.


My feeling about Vitamin D was a gut feeling, sorry for the pun. I could believe that it affected the microbiome but which vitamin D the measured one or some other active form and the problem was with the conversion of measured one into the active form ?


The answer arrived from a recently published study .

Vitamin D metabolites and the gut microbiome in older men

Nature Communications 

volume

 11, Article number: 5997 (2020) 




The vitamin D receptor is highly expressed in the gastrointestinal tract where it transacts gene expression. With current limited understanding of the interactions between the gut microbiome and vitamin D, we conduct a cross-sectional analysis of 567 older men quantifying serum vitamin D metabolites using LC-MSMS and defining stool sub-Operational Taxonomic Units from16S ribosomal RNA gene sequencing data. Faith’s Phylogenetic Diversity and non-redundant covariate analyses reveal that the serum 1,25(OH)2D level explains 5% of variance in α-diversity. In β-diversity analyses using unweighted UniFrac, 1,25 (OH)2D is the strongest factor assessed, explaining 2% of variance. Random forest analyses identify 12 taxa, 11 in the phylum Firmicutes, eight of which are positively associated with either 1,25(OH)2D and/or the hormone-to-prohormone [1,25(OH)2D/25(OH)D] “activation ratio.” Men with higher levels of 1,25(OH)2D and higher activation ratios, but not 25(OH)D itself, are more likely to possess butyrate producing bacteria that are associated with better gut microbial health.


Because the serum 25(OH)D correlates with overall vitamin D storage, it is the preferred clinical measure to assess vitamin D sufficiency. Clinically, serum 25(OH)D levels ≥20 ng/ml are considered adequate while 25(OH)D levels <20 ng/ml are defined as vitamin D deficiency. However, it is the active form of vitamin D, 1,25(OH)2D, that interacts specifically with the vitamin D receptor (VDR) and transacts gene expression. Under tight feedback control, 1,25(OH)2D also induces the expression of catabolic 24-hydroxylase that converts 25(OH)D to 24,25(OH)2D and 1,25(OH)2D to 1,24,25(OH2D) metabolites13. Ratios of vitamin D activation (1,25(OH)2D/25(OH)D) and catabolism (24,25(OH)2D/25(OH)D) quantify the proportion of vitamin D stores that are being processed (activated or catabolized) and can serve as a measure of vitamin D mobilization for use in endocrine signaling, or vitamin D flux. These ratios relative to total vitamin D stores based upon 25(OH)D levels may be better predictors of clinically important outcomes including incident hip fracture and earlier mortality


Renal 1α-Hydroxylation

25(OH)D must be further hydroxylated to gain hormonal bioactivity. This occurs in the convoluted and straight portions of the proximal kidney tubuleHydroxylation at position 1α by the mitochondrial cytochrome P450 enzyme 25-hydroxyvitamin D-1α-hydroxylase (CYP27B1; hereafter referred to as 1α-hydroxylase) converts 25(OH)D to 1,25(OH)2D, the active, hormonal form of vitamin D.

  In clinical settings we have been measuring 25 OH-vitamin D and they set arbitrary limits of what is deficiency and what is normal value.  At one time values lower than 30 ng/ml were considered abnormal but for clinical purposes single digit numbers attract my attention for immediate action and the values 10-20 for further action. 


Someone from the American University at Beirut had written:

despite its abundant sunshine the Middle East, a region spanning latitudes from 12°N to 42°N allowing vitamin D synthesis year round, registers some of the lowest levels of vitamin D and the highest rates of hypovitaminosis D worldwide. This major public health problem affects individuals across all life stages including pregnant women, neonates, infants, children and adolescents, adults, and the elderly.


So there has to be a rethink in the world of Vitamin D.. what is the normal level for good metabolic function? And how do we measure it ? And should we be giving so much supplementation on people who may not need supplementation? 


It would be nice to do do 25 0h vitamin D levels as well as 1 25 OH vitamin D levels and see how this would influence our treatment of this “fictitious” laboratory illness or be proved wrong.

Let us give it a try.


How much Vitamin D supplementation does this Florida native need ?





The metabolism and biologic function of vitamin D. During exposure to sunlight, 7-dihydrocholesterol (7-DHC) is photolyzed to previtamin D3 (preD3). Body heat converts preD3 to vitamin D3. Vitamin D2 and vitamin D3 in the diet and vitamin D made in the skin enters the circulation and either is stored in the body’s fat adipocytes or enters the liver and is converted to 25-hydroxyvitamin D [25(OH)D]. For regulation of calcium metabolism, 25(OH)D is converted in the kidneys to 1,25-dihydroxyvitamin D [1,25(OH)2D]. 1,25(OH)2D interacts with its vitamin D receptor (VDR) in the small intestine and on osteoblasts to regulate calcium and phosphorus metabolism. 25(OH)D is metabolized in various tissues and cells for regulating cellular proliferation and differentiation as well as inducing cathelicidin D(CD) in macrophages. The induction of 1,25(OH)2D in the macrophage is controlled by the 2/1 toll-like receptors (TLR) and its interaction with lipopolysaccharide (LPS). In addition, circulating concentrations of 1,25(OH)2D may help increase insulin production and decrease renin production and alter adipocyte lipogenesis.  thanks to Michael Hollick.

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